Failure to Provide Timely and Consistent Care, Monitoring, and Treatment
Penalty
Summary
Three residents did not receive necessary care and treatment as required by physician orders, facility policy, and their individual care plans. One resident with chronic kidney disease, diabetes, and a history of pressure injuries did not have weekly skin assessments completed for three weeks. When a new skin impairment was observed, there was no comprehensive assessment, no treatment initiated, and no care plan revision at the time the issue was first identified. Documentation was inconsistent, and the wound was not properly classified or communicated to all relevant parties until several days later. Another resident with heart failure and fluid overload had physician orders for daily weights and strict fluid intake monitoring. However, fluid intake was not consistently documented, with many days missing numerical values or any record at all. Daily weights were also not consistently recorded, and staff interviews revealed a lack of clarity and compliance with documentation procedures. The resident's care plan and Kardex did not consistently reflect the fluid restriction order, and staff were not always aware of or following the monitoring requirements. A third resident with a urinary tract infection and pressure ulcer had a urinalysis ordered, but the specimen was not processed for over a week due to improper labeling. This resulted in a delay in diagnosis and treatment, as the antibiotic was not ordered until after the test was finally completed. Staff interviews confirmed that the labeling error and lack of timely communication with the laboratory led to the delay in processing the specimen and initiating appropriate treatment.